Scarce resources for BPD patients

A GP treating patients with borderline personality disorder has questioned the practical application of an MJA editorial that presents an optimistic prognosis for the disorder. (1)

“Where are the resources?” Dr Darryl Lacey, a Perth GP, asked. “The NHMRC guidelines appear to be recommending that 1%–4% of the population be referred for specialist BPD [borderline personality disorder] therapy — where are the resources?” (2)

Dr Lacey told MJA InSight that consultations with patients with BPD typically provoked negative emotions in GPs because of the patients’ behaviour problems.

The MJA editorial said more than 25 randomised controlled trials had demonstrated that specific types of psychotherapy are known to be effective with BPD patients, including dialectical behavioural therapy, mentalisation-based therapy, and transference-focused therapy.

“Effective treatments aim to strengthen self-esteem and use the therapist-patient or doctor-patient relationship to provide a ‘safe place’ for the patient to discuss alternatives to destructive behaviour and relationship insecurities, with an unhurried, step-by-step ‘here and now’ approach to improve daily functioning”, wrote Professor Brin Grenyer, of the school of psychology at the University of Wollongong.

However, Dr Lacey said where he practised in the southern suburbs of Perth, publicly funded dialectical behaviour therapy was extremely limited.

“There is also the difficulty that failure to attend appointments is a typical feature of BPD. This commonly results in the sequence of refer to clinic, failed to attend, failed to attend again so discharged from clinic but feel free to send another referral if appropriate.”

Dr Lacey said private psychological services were “almost entirely driven” by the Medicare funding system, which he described as a basic premise of short-term therapy for specific, time-limited, simple psychological problems.

“The chronic relationship difficulties, impaired educational achievement, self injury and impulsiveness of people with BPD tend to be associated with a complex network of physical problems, substance-related problems and psychological distress”, he said.

“The net result of all this is that the GP provides most of the care for people with BPD and those with traits not meeting the diagnosis.

“These patients typically attend in crisis, desperate to be given priority over other patients, unable to wait for a timely appointment. They also typically arrive late or not at all for booked appointments. The GP’s failure to provide the desired quick solution to the BPD patient’s intense distress typically results in frequent change of practitioner, further impairing the potential for a long-term therapeutic relationship.”

Dr Paul Morgan, director of communications with SANE Australia, agreed that the consistency and the long-term nature of the doctor-patient relationship was crucial to successful BPD therapy, but pointed out there were some excellent programs already in place.

“It’s not so long ago — less than a generation — that BPD was not even accepted as a mental health problem in this country”, said Dr Morgan, who was a consultant on the NHMRC guidelines.

“Now there is acceptance and some very good projects. Victoria has Spectrum, which is a well established program funded by the health department there. NSW also has an excellent program.

“Are they adequately funded? Probably not, but those are the problems right across health care”, he said.

Dr Morgan said it was particularly problematic finding treatment for BPD patients because it was hard to find people who understood the disorder and its treatments. “BPD tends to amplify the challenges of other mental health disorders.

“It would be great if that help was more easily accessible”, he said.
 

1. MJA 2013; 198: 464-465
2. NHMRC 2012; Clinical Practice Guideline for the Management of Borderline Personality Disorder